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ID

11389

Beskrivning

Southwest Oncology Group Lung Carcinoma Follow Up Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CDF62A-7230-112A-E034-080020C9C0E0

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CDF62A-7230-112A-E034-080020C9C0E0

Nyckelord

  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2015-07-03 2015-07-03 -
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3 juli 2015

DOI

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Creative Commons BY-NC 3.0 Legacy

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    Southwest Oncology Group Lung Carcinoma Follow Up Form

    No Instruction available.

    1. StudyEvent: Southwest Oncology Group Lung Carcinoma Follow Up Form
      1. No Instruction available.
    SWOG clinical trial administrative data
    Beskrivning

    SWOG clinical trial administrative data

    SWOG Patient ID
    Beskrivning

    SWOGPatientID

    Datatyp

    text

    SWOG Study No.
    Beskrivning

    SWOGStudyNo.

    Datatyp

    text

    Registration Step
    Beskrivning

    RegistrationStep

    Datatyp

    text

    Patient Initials (L, F M)
    Beskrivning

    Patient Initials

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C2986440 (Person Initials)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25536 (undefined)
    Institution/Affiliate
    Beskrivning

    MainMemberInstitution/Affiliate

    Datatyp

    text

    Physician (Groups other than SWOG)
    Beskrivning

    RegisteredInvestigator

    Datatyp

    text

    Group Name
    Beskrivning

    GroupName

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS 2011AA ValueDomain
    C1547383 (Person Name)
    SNOMED
    734006007
    NCI Thesaurus ObjectClass
    C17005 (undefined)
    UMLS 2011AA ObjectClass
    C1257890 (Population Group)
    SNOMED
    389109008
    LOINC
    LA12078-4
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    Study No.
    Beskrivning

    StudyNo.

    Datatyp

    text

    Pt. ID (Vital Status)
    Beskrivning

    Pt.ID

    Datatyp

    text

    Lung Carcinoma Follow Up
    Beskrivning

    Lung Carcinoma Follow Up

    Vital Status
    Beskrivning

    Patient'sVitalStatus

    Datatyp

    text

    Date of last contact or death (If vital status is Dead, complete and submit Notice of Death form.)
    Beskrivning

    DeathDate/LastContactDate

    Datatyp

    date

    Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
    Beskrivning

    CancerFollow-upStatusInd

    Datatyp

    boolean

    Date of Last Clinical Assessment (Notice of First Relapse or Progression)
    Beskrivning

    CancerFollow-upStatusDate

    Datatyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C2991 (undefined)
    UMLS 2011AA ObjectClass
    C0012634 (Disease)
    SNOMED
    64572001
    LOINC
    LP21006-9
    NCI Thesaurus Property
    C25365 (undefined)
    UMLS 2011AA Property
    C0678257 (Description)
    LOINC
    LP6800-9
    Has the patient developed a first progression (or relapse) that has not been previously reported?
    Beskrivning

    ProgressionInd

    Datatyp

    boolean

    Date of Relapse or Progression (If yes, please submit the Lung Carcinoma First Sites of Progression or Relapse Form.)
    Beskrivning

    ProgressionDate

    Datatyp

    date

    Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported? (If yes,)
    Beskrivning

    NewPrimaryCancerInd

    Datatyp

    boolean

    Date of Diagnosis
    Beskrivning

    NewPrimaryCancerDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    New Primary Site (Further Treatment)
    Beskrivning

    NewPrimarySite

    Datatyp

    text

    Has the patient received further (non-protocol) treatment for this cancer? (If yes,)
    Beskrivning

    Non-ProtocolTherapyInd

    Datatyp

    boolean

    Date of first non-protocol therapy
    Beskrivning

    Non-ProtocolTherapyDate,First

    Datatyp

    date

    Specify regimen (Note: If multiple regimens were received, please specify only the first regimen received after going off protocol treatment.)
    Beskrivning

    Non-ProtocolTherapyType

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C25590 (undefined)
    UMLS 2011AA ObjectClass
    C1518384 (Non-Protocol)
    NCI Thesaurus ObjectClass-2
    C2167 (undefined)
    UMLS 2011AA ObjectClass-2
    C1443775 (Epidermal growth factor receptor inhibitor (product))
    SNOMED
    409402009
    NCI Thesaurus Property
    C25382 (undefined)
    UMLS 2011AA Property
    C1521801 (Having administered)
    Did the patient respond to this treatment?
    Beskrivning

    Didthepatientrespondtothistreatment?

    Datatyp

    boolean

    Has the patient received prophylactic cranial irradiation (PCI)?
    Beskrivning

    prophylactic cranial irradiation

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148 (undefined)
    UMLS CUI-1
    C1514496 (Prophylactic Cranial Irradiation)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25639 (undefined)
    NCI Thesaurus Property-2
    C15913 (undefined)
    PCI Start Date (Long Term Toxicity)
    Beskrivning

    PCIStartDate

    Datatyp

    text

    Toxicities and Grades
    Beskrivning

    CTCAdverseEventTerm

    Datatyp

    text

    Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade>/=3) long term toxicity that has not been previously reported?
    Beskrivning

    Hasthepatientexperienced(priortotreatmentforprogressionorrelapseorasecondprimary,andpriortonon-protocoltreatment)anysevere(grade>/=3)longtermtoxicitythathasnotbeenpreviouslyreported?

    Datatyp

    boolean

    Comments
    Beskrivning

    Comments

    Comments
    Beskrivning

    Comments

    Datatyp

    text

    Ccrr Module For Southwest Oncology Group Lung Carcinoma Follow Up Form
    Beskrivning

    Ccrr Module For Southwest Oncology Group Lung Carcinoma Follow Up Form

    Similar models

    No Instruction available.

    1. StudyEvent: Southwest Oncology Group Lung Carcinoma Follow Up Form
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    Alias
    Item Group
    SWOG clinical trial administrative data
    SWOGPatientID
    Item
    SWOG Patient ID
    text
    SWOGStudyNo.
    Item
    SWOG Study No.
    text
    RegistrationStep
    Item
    Registration Step
    text
    Patient Initials
    Item
    Patient Initials (L, F M)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    MainMemberInstitution/Affiliate
    Item
    Institution/Affiliate
    text
    RegisteredInvestigator
    Item
    Physician (Groups other than SWOG)
    text
    GroupName
    Item
    Group Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C17005 (NCI Thesaurus ObjectClass)
    C1257890 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    StudyNo.
    Item
    Study No.
    text
    Pt.ID
    Item
    Pt. ID (Vital Status)
    text
    Item Group
    Lung Carcinoma Follow Up
    Item
    Vital Status
    text
    Code List
    Vital Status
    CL Item
    Alive (Alive)
    CL Item
    Dead (Dead)
    DeathDate/LastContactDate
    Item
    Date of last contact or death (If vital status is Dead, complete and submit Notice of Death form.)
    date
    CancerFollow-upStatusInd
    Item
    Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
    boolean
    CancerFollow-upStatusDate
    Item
    Date of Last Clinical Assessment (Notice of First Relapse or Progression)
    date
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    ProgressionInd
    Item
    Has the patient developed a first progression (or relapse) that has not been previously reported?
    boolean
    ProgressionDate
    Item
    Date of Relapse or Progression (If yes, please submit the Lung Carcinoma First Sites of Progression or Relapse Form.)
    date
    NewPrimaryCancerInd
    Item
    Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported? (If yes,)
    boolean
    NewPrimaryCancerDate
    Item
    Date of Diagnosis
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    NewPrimarySite
    Item
    New Primary Site (Further Treatment)
    text
    Non-ProtocolTherapyInd
    Item
    Has the patient received further (non-protocol) treatment for this cancer? (If yes,)
    boolean
    Non-ProtocolTherapyDate,First
    Item
    Date of first non-protocol therapy
    date
    Non-ProtocolTherapyType
    Item
    Specify regimen (Note: If multiple regimens were received, please specify only the first regimen received after going off protocol treatment.)
    text
    C25590 (NCI Thesaurus ObjectClass)
    C1518384 (UMLS 2011AA ObjectClass)
    C2167 (NCI Thesaurus ObjectClass-2)
    C1443775 (UMLS 2011AA ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    Didthepatientrespondtothistreatment?
    Item
    Did the patient respond to this treatment?
    boolean
    prophylactic cranial irradiation
    Item
    Has the patient received prophylactic cranial irradiation (PCI)?
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1514496 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25639 (NCI Thesaurus Property)
    C15913 (NCI Thesaurus Property-2)
    PCIStartDate
    Item
    PCI Start Date (Long Term Toxicity)
    text
    CTCAdverseEventTerm
    Item
    Toxicities and Grades
    text
    Hasthepatientexperienced(priortotreatmentforprogressionorrelapseorasecondprimary,andpriortonon-protocoltreatment)anysevere(grade>/=3)longtermtoxicitythathasnotbeenpreviouslyreported?
    Item
    Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade>/=3) long term toxicity that has not been previously reported?
    boolean
    Item Group
    Comments
    Comments
    Item
    Comments
    text
    Item Group
    Ccrr Module For Southwest Oncology Group Lung Carcinoma Follow Up Form

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